29 SCHOOL ST - BUILDING INSPECTION Y
flwNSIAWSTIDEf *04► G APPROVED 9Y T4IE
.IMSP=DB PMOR TD A_PERMIT B,EWG GRANTkD
CITY OF SALEM
No)'ZJ\ _
Date
is
Ward
\ � R
Zoning District
Is Property Located in Location of
the Historic District? Yes No ?landing
Is PropeAy Located in �j SeN_�Jt
the CWmmtlon Area? Yes No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roo Reroof . stall Siding, Construct Deck, Shed, Pool,
Repair ep Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build acconArig,to the.following
specifications:
Owners Name CA
Address & Phone S7 fl-�% -7�a4- 2�00
Architect's Name
Address & Phone t
Mechanics Name
Address & Phone S LDQZt-`%
What is the purpose of building? YC �JN 2
Malarial of buildlrq? If a dwelling,for how many families?
Will building conform to law? y LS Asbestos? 0 D
Estimated cold !fl3 S O Clly License N State License N
Rommi S,— S4i k-j e S
Lie. /
Signature of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
j t
No.
APPLICATION FOR
PERMIT TO
I LOCATION
PERMIT GRANTED
19
APPROVED
INSPECTOR OF BUI INGS
- PUSUG PROPERTY DEPARTMENT
12O WA5H1Ha OM STRELT, saDFLDos
SAL[M,MA O t S70
TEL (976)745-S595 EXT.360
FAX (979) 740.98"
STANLEY J. Usovocz, JR..
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the proviaiom of MGL c 40,534,1 aclmowledge dim as a cmMm
of Building Permit g &Udd)irismuWmSfmmtwcmomcdmwdvity
governed by this Building Pemrit shad be disposed Of in a propaly liceosed solid-wmu
disposal facility,as defined by M(IL c IM S150A.
The debris will be disposed of at g I �f>Q� 'i P qFO y c
Location of Facility
S:0
s,_
Signature of Permit Applicant Dam
FULLY complete mS
(PLEASE PRINT C the LEARu L ) m&mj5ftm
Name ofPemrit Applicant
Firm Name,if any
Address,city A State
The above statute requires that debris from the demolition,renovation,rehab or otters•
alteration of building or suuct(ne be disposed in a properly-licensed solid-waste disposal
5cility as defined by MGI,cI%S1SOA, and the building perm or liceaaa am to
indicate the location of the may.
COMMO tud6tLA 0/Mauzchu &
' 1JePaaiwaa����/rlfri��� '
600 Ula. e S+asat
James 1 C.aaaat &d o% Mesa" 02111
Workers' Compensssim Isaursum Af Ulwk
1, b is �N t�Cs t QOdkt4G
. . widls pr6cipd pba o1 btniaass SC
Sr I S LOW Jbi
do hereby'cer* under On paint and peasldw of parJety, claw
I an an anple)w providing workers' co npemtlee coverage for mq eiapleygM working on
�1. STAl lf� S,Uyko z �O', 1.k3 C Ll3j S 102�
Insumna Compeay Po Ntaa6er
1 an :sole proprietor and have no eon working fir rase to any espocky.
0 1 am a sole proprksor, general contractor or homeowner (circle ome) sad have lard tie
contractors listed below who-hew the feillowing workers' eosnpetssstkns pe6deas '
Centracto► Insunnie CompwW/Popgr Nusraber
Contractor Insurance Company/Po Number
Csnuacter insurance Company/Poliq Number
0 1 am s homeowner performing all the work myself.
•I raftmme am a Col of di ANwarw N be for..ar"d a ON cxke A bwuk aae of dw M fer eareraOr.wikedw nay an MAN w wart
rowrare a rreerre nra Soda 21a M MGL 1 S 2 can In"Y NOW Wwood"Of oiainn Oeaads eerand"Of e W of a 041 500 muter nee
traq':OOraemrw a ve a dd smAido in iMr lone of a STOP WORK ORD ER ate a br Of s loom a an aphog wa.
Signed this . day of
:icenscciFcnn4tee euilding Department
ucensinf Ecare
Selectmen Office
=eslch Gepsrment
_ - _ = :_ : _ ye : _ 404 405 ape 17c
RLi r]-S fir 411..M fl YO I t�iyk'= L.U �.`:. _ - _Li i',F P. 0115i1105
i
ter^
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, CERTIFICA` E OF LIABIL11-YY_INSURANCE � OV2710GRn+r1
A6r
PROPUCCR 7HIS CERTOviCATE IS 155;=AS A;MA7FR OF INFORMAT10N
C.K MCGa�thy Ins,AgCy,IRO, � �— ONLY AND CONFcR$NO RIGHTS UPON THE CERTIFICATE
HOLDER.T141S CERTMC ,TE DOTS NO. Ab1END,EXTEND OR
10 Cantonni«I Drivo A4TER THE COVERAGE AFFORDED BYTHE POLICIES MOW. �f
Peabody , MA o1960 ' ��II
.473 532.5445 INSURERS AFFORDING COVERAIM l NAIC d
INsunee INsuntrl: Conaxea Insurance AOcacy
?deafen Pro .aRy csarv{ce�,LLC WSUR0Ra: Tho Travelers Insurance Company.
)1 Olymp4:: Painting&Roofing e �to - - -- -
I rsunena Granite State insurance Co I
. Andavcr Strout,Sulto 391 wsunen D:
1 atody ,MA 01960
NSuntn t:- _-- -
COVERACF"i
THE POLICIES C- ED SELO6V l7vC OCCN iC$UCp TC THE INSURFO NAM---D ASOVE FOR`PIE POU=PCP It"1NOICATED.Nt)lWiTHSTG;NDI4G
ANY REGUrgCN1CNTTCRA7 OR CCNCITION OF A.NY CONTT.AOT OR OTHER DOCUMENT WITH REGPCCT TO'V:HICk'YH!4 CenTIP=ATE.PLAY SF GSUcD OR
MAY RERTAIN,Tiic IN"URA•1C'F AFFORDEO V rHC POLICIES Oe`Ck!SED I-EREIN IS SUBJ=r'CO ALL TNT TC M&;CXCLU°ONS AND CONDITIONS OF SUCH
POi_ICI S.AGCRCOATE LIMITS SHOWN MAY HAVF 5EFN AeMUOED 9Y PAZ CLAIMS.
1 TYPt DP INEUKMaR POJCYNyw!UR NUR kpD, OEYAT PnATP l MIT;uiipil LIMfTS
A � ctNEHALUApnJ7Y NF'P899339 '0611710�1T(05 LACHoecuRi.CNCE I s'I 00 000
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_ i CENtIVJ.ACCHEOATB $2 DUO 000 N
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I3 AurawOa.t,tAsilrt'T 181--0404BA03TIND010115103
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ANY Au10 ICAO Ulu $500,000
ALLCWINEOAUTOO no011.7 01JURY q X CcriCC664DA"s - mWj1BfCA1I
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GMf vaT»RS'.:Aall°T eL AAVHAG 10A,lT SSGD 000
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cRN tswMcsla a� LLeo-r � cL.u A,c CAtIAneYttl$500 00C I
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`rho earti{estchoidor Is listed as addldonal Insured with rospaet to
liability arising Out of the named InsuTad's oparatlelns pOlDrmad on behalf
III at�certittcataholdor.
CERTI61CATC HOLDER CANCELEATION_
SHOULA MY GP-Tit ABOVE DESCRinEU POUCIE6 DH C"GOLLAD IWORC 1NC R.YPIRA7108
DATE THlt1A0P,THdISA::W41N`tL'ND.4 N'ILI,P_NOt-AVORN NAIL _111e. OAYJN1eIrMN
NOTFcz TO7141!=m1F1c4T2 HOLCSn Ruy£A-,Oi,TH4 DAFT,OUT P111LURL TO Do to SHALL
AW1234 NO 05LICATION OR LIFa16,1" 4 D Ha 1N SDRt✓4.rr1 AOPHTS on
RpIagOL'N,ATIV25,
AUTHO=9D RCPR6UDN:4AaTVO � •
9 c ACORD CORPCRA71ON 10aa
ACORD 25(200TIOSj 1 cfn,. #A54.10 1e.v